The nursing implications of routine provider-initiated HIV testing and counselling in sub-Saharan Africa: a critical review of new policy guidance from WHO/UNAIDS.

BACKGROUND: In 2007 WHO/UNAIDS issued new HIV testing guidelines recommending 'provider-initiated HIV testing and counselling' (PITC). In contrast to existing 'voluntary counselling and testing' guidelines (whereby individuals self refer for testing), the PITC guidance recommends that, in countries with generalised epidemics, all patients are routinely offered an HIV test during clinical encounters. In sub-Saharan Africa, PITC aims to dramatically increase HIV testing rates so that PITC becomes a vehicle to increase access to HIV prevention and care. Nurses in this region work on the frontlines of HIV testing but have been neglected in related policy development. AIM: To provide an overview of the PITC policy guidance and to critically consider its implications for the nursing profession in sub-Saharan Africa.
METHODS: Policy documents and published and unpublished research were identified from organisational websites, electronic databases and conference proceedings.
RESULTS: PITC has generated widespread debate about whether it is the right approach in a context of HIV-related stigma and lack of human/material resources. Key concerns are whether/how informed consent, privacy and confidentiality will be upheld in overstretched health care settings, and whether appropriate post-test counselling, treatment and support can be provided. Limited available evidence suggests that health systems factors and organisational/professional culture may create obstacles to effective PITC implementation. Specific findings are that: PITC greatly increases nurses' workload and work-related stress. Nurses are generally positive about PITC, but express the need for more training and managerial support. Health system constraints (lack of staff, lack of space) mean that nurses do not always have time to provide adequate counselling. A hierarchical and didactic nursing culture affects counselling quality and the boundaries between voluntary informed consent and coercion can become rather blurred. Nurses are particularly stressed by breaking bad news and handling ethical dilemmas.
CONCLUSION: Three areas are identified in which the PITC implementation process needs to be strengthened: (i) research/audit (to explore nurse and patient experiences, to identify best practice and key obstacles), (ii) greater nurse participation in policy development, (iii) strengthening of nurse training and mentoring.